The Annual Meeting Of the American Academy Of Cosmetic Surgery

LAS VEGAS – Current radiofrequency technologies, which yield measurable results in little or no down time, have altered the way clinicians and patients alike think about cervicofacial skin tightening and reduction of body fat, according to Dr. Paul J. Carniol.

"These devices do not replace surgery," he said at the annual meeting of the American Academy of Cosmetic Surgery. "They do not replace a facelift or liposuction, but they have a role for patients who tell you they don’t want to undergo a surgical procedure."

As radiofrequency (RF) technology evolves, its application in cosmetic dermatology "is just going to get better," predicted Dr. Carniol, a cosmetic, laser, and reconstructive plastic surgeon in Summit, N.J. "It’s something to keep your eye on because these devices have changed in the past few years, and they continue evolving."

He discussed his experience using the Pellevè Wrinkle Reduction System (Ellman International, Oceanside, N.Y.) for skin tightening and wrinkle reduction. This 4.0-MHz high-frequency RF device produces lateral thermal spread on the dermal layer of skin, reducing the risk of injury to surrounding tissue and structures. Therapeutic levels of heat delivered at intradermal temperatures that range from 39 to 53  C induce collagen contraction, neocollagenesis, and elastin uniformity, resulting in firmer, denser rejuvenated skin with restored elasticity. The initial wound healing response takes 3-4 weeks.

"It’s great for the patient who comes in and wants no down time, a little bit of tightening, and they want some global facial rejuvenation," Dr. Carniol said of the Pellevè system, which was cleared by the Food and Drug Administration in 2009 for the nonablative treatment of mild to moderate facial wrinkles and rhytids for Fitzpatrick skin types I-IV. The technology is contraindicated for patients with pacemakers, implantable cardioverter defibrillators, and any other implanted devices.

In one study, 93 patients were followed for 6 months after a single treatment with the Pellevè system. The response rate was determined by three independent, blinded assessors, including two facial plastic surgeons and one dermatologist (J. Drugs Dermatol. 2007;6:381-6). The response rates at 30, 90, and 180 days were 90.3%, 88.2%, and 87.1%, respectively.

In Dr. Carniol’s clinical experience, the ideal patients for the Pellevè system include those aged 35-60 years who present with modest to moderate laxity, but relatively elastic skin, moderate submental sagging, lax jaw lines and early jowls, moderate nasolabial folds, perioral and periorbital wrinkles, and/or relatively thin connective tissue layers. "You also want patients who aren’t that heavy," he said. "If someone is very overweight, the device is not going to work because the effect of all the excess tissue is too much."

Other poor candidates for the procedure include those with severely photodamaged skin, severe laxity or sagging, very deep wrinkles or muscle motion–induced rhytids, thick connective tissues, and/or unrealistic expectations. Post treatment, he said, "there is essentially no down time, which is one of the reasons that it’s such a great procedure, because your patients can take a break from work, come in, and return right to work."

His posttreatment instructions include washing the skin with tepid water and a gentle cleanser, use of nonirritating moisturizers, and use of sun block with UVA and UVB protection with an SPF of 30 or greater. The Pellevè treatment may be combined with fractionated resurfacing, but RF treatment "should be done at least 4 weeks prior to the laser treatment," he advised. "Pellevè may also be given with other treatments such as neurotoxins and fillers. Most physicians recommend this either at least 2 weeks prior to radiofrequency or at 1-2 weeks after injection after tissue reactions have subsided."

He also advised suspending the use of topical agents, which may cause erythema or irritation, for a week before and a week after Pellevè treatment; these agents include retinol/Retin-A (tretinoin)/isotretinoin, glycolic acid, and salicylic acid.

Dr. Carniol also discussed his experience with truSculpt (Cutera, Brisbane, Calif.), a monopolar RF device cleared for deep tissue heating and the temporary reduction in the appearance of cellulite. It features a large applicator that delivers energy 1.3-3 cm into the skin to targeted subcutaneous tissue before dispersing in underlying highly conductive fluids and tissues. The goal is for patients to be treated at the highest temperature that they can comfortably tolerate, typically between 42 and 46  C. Pulse durations of 4 minutes are recommended for each imprint. "Treatment should be uncomfortable, but not unbearable," he said. "Moderate hyperemia is expected and will persist for several hours."

The subcutaneous heating creates apoptosis, "a process whereby the cells resorb over a period of 3-12 weeks," explained Dr. Carniol. "It’s a very slow and gradual loss of fat cells compared with necrosis, which gives you instantaneous cell death and an acute inflammatory response and indurations."

The truSculpt device includes a proprietary contoured design to ensure uniform delivery and current. The electrode is available in four sizes: 15 cm², 25 cm², 30 cm², and 40 cm². This design "optimizes treatment uniformity over large exposure areas, which results in enhanced patient comfort and no hot spots or edge effects to cause pain," Dr. Carniol said.

Studies using before and after ultrasound images have demonstrated that the technology reduces treated areas of subcutaneous fat by up to 25%. "In general, I don’t think you see as much improvement with just one treatment," he noted. "I think it takes two to three treatments for best results."

In his clinical experience, the ideal patients for the procedure include those in generally good health with a body mass index between 22 and 28 kg/m² who have focal areas that they want reduced. The device is indicated for use on all Fitzpatrick skin types and tanned skin.

Dr. Carniol disclosed that he has given presentations for Ellman and Cutera, but said that he has no relevant financial interests in either company.

dbrunk@frontlinemedcom.com

LAS VEGAS – Current radiofrequency technologies, which yield measurable results in little or no down time, have altered the way clinicians and patients alike think about cervicofacial skin tightening and reduction of body fat, according to Dr. Paul J. Carniol.

"These devices do not replace surgery," he said at the annual meeting of the American Academy of Cosmetic Surgery. "They do not replace a facelift or liposuction, but they have a role for patients who tell you they don’t want to undergo a surgical procedure."

As radiofrequency (RF) technology evolves, its application in cosmetic dermatology "is just going to get better," predicted Dr. Carniol, a cosmetic, laser, and reconstructive plastic surgeon in Summit, N.J. "It’s something to keep your eye on because these devices have changed in the past few years, and they continue evolving."

He discussed his experience using the Pellevè Wrinkle Reduction System (Ellman International, Oceanside, N.Y.) for skin tightening and wrinkle reduction. This 4.0-MHz high-frequency RF device produces lateral thermal spread on the dermal layer of skin, reducing the risk of injury to surrounding tissue and structures. Therapeutic levels of heat delivered at intradermal temperatures that range from 39 to 53  C induce collagen contraction, neocollagenesis, and elastin uniformity, resulting in firmer, denser rejuvenated skin with restored elasticity. The initial wound healing response takes 3-4 weeks.

"It’s great for the patient who comes in and wants no down time, a little bit of tightening, and they want some global facial rejuvenation," Dr. Carniol said of the Pellevè system, which was cleared by the Food and Drug Administration in 2009 for the nonablative treatment of mild to moderate facial wrinkles and rhytids for Fitzpatrick skin types I-IV. The technology is contraindicated for patients with pacemakers, implantable cardioverter defibrillators, and any other implanted devices.

In one study, 93 patients were followed for 6 months after a single treatment with the Pellevè system. The response rate was determined by three independent, blinded assessors, including two facial plastic surgeons and one dermatologist (J. Drugs Dermatol. 2007;6:381-6). The response rates at 30, 90, and 180 days were 90.3%, 88.2%, and 87.1%, respectively.

In Dr. Carniol’s clinical experience, the ideal patients for the Pellevè system include those aged 35-60 years who present with modest to moderate laxity, but relatively elastic skin, moderate submental sagging, lax jaw lines and early jowls, moderate nasolabial folds, perioral and periorbital wrinkles, and/or relatively thin connective tissue layers. "You also want patients who aren’t that heavy," he said. "If someone is very overweight, the device is not going to work because the effect of all the excess tissue is too much."

Other poor candidates for the procedure include those with severely photodamaged skin, severe laxity or sagging, very deep wrinkles or muscle motion–induced rhytids, thick connective tissues, and/or unrealistic expectations. Post treatment, he said, "there is essentially no down time, which is one of the reasons that it’s such a great procedure, because your patients can take a break from work, come in, and return right to work."

His posttreatment instructions include washing the skin with tepid water and a gentle cleanser, use of nonirritating moisturizers, and use of sun block with UVA and UVB protection with an SPF of 30 or greater. The Pellevè treatment may be combined with fractionated resurfacing, but RF treatment "should be done at least 4 weeks prior to the laser treatment," he advised. "Pellevè may also be given with other treatments such as neurotoxins and fillers. Most physicians recommend this either at least 2 weeks prior to radiofrequency or at 1-2 weeks after injection after tissue reactions have subsided."

He also advised suspending the use of topical agents, which may cause erythema or irritation, for a week before and a week after Pellevè treatment; these agents include retinol/Retin-A (tretinoin)/isotretinoin, glycolic acid, and salicylic acid.

Dr. Carniol also discussed his experience with truSculpt (Cutera, Brisbane, Calif.), a monopolar RF device cleared for deep tissue heating and the temporary reduction in the appearance of cellulite. It features a large applicator that delivers energy 1.3-3 cm into the skin to targeted subcutaneous tissue before dispersing in underlying highly conductive fluids and tissues. The goal is for patients to be treated at the highest temperature that they can comfortably tolerate, typically between 42 and 46  C. Pulse durations of 4 minutes are recommended for each imprint. "Treatment should be uncomfortable, but not unbearable," he said. "Moderate hyperemia is expected and will persist for several hours."

The subcutaneous heating creates apoptosis, "a process whereby the cells resorb over a period of 3-12 weeks," explained Dr. Carniol. "It’s a very slow and gradual loss of fat cells compared with necrosis, which gives you instantaneous cell death and an acute inflammatory response and indurations."

The truSculpt device includes a proprietary contoured design to ensure uniform delivery and current. The electrode is available in four sizes: 15 cm², 25 cm², 30 cm², and 40 cm². This design "optimizes treatment uniformity over large exposure areas, which results in enhanced patient comfort and no hot spots or edge effects to cause pain," Dr. Carniol said.

Studies using before and after ultrasound images have demonstrated that the technology reduces treated areas of subcutaneous fat by up to 25%. "In general, I don’t think you see as much improvement with just one treatment," he noted. "I think it takes two to three treatments for best results."

In his clinical experience, the ideal patients for the procedure include those in generally good health with a body mass index between 22 and 28 kg/m² who have focal areas that they want reduced. The device is indicated for use on all Fitzpatrick skin types and tanned skin.

Dr. Carniol disclosed that he has given presentations for Ellman and Cutera, but said that he has no relevant financial interests in either company.

dbrunk@frontlinemedcom.com

LAS VEGAS – Current radiofrequency technologies, which yield measurable results in little or no down time, have altered the way clinicians and patients alike think about cervicofacial skin tightening and reduction of body fat, according to Dr. Paul J. Carniol.

"These devices do not replace surgery," he said at the annual meeting of the American Academy of Cosmetic Surgery. "They do not replace a facelift or liposuction, but they have a role for patients who tell you they don’t want to undergo a surgical procedure."

As radiofrequency (RF) technology evolves, its application in cosmetic dermatology "is just going to get better," predicted Dr. Carniol, a cosmetic, laser, and reconstructive plastic surgeon in Summit, N.J. "It’s something to keep your eye on because these devices have changed in the past few years, and they continue evolving."

He discussed his experience using the Pellevè Wrinkle Reduction System (Ellman International, Oceanside, N.Y.) for skin tightening and wrinkle reduction. This 4.0-MHz high-frequency RF device produces lateral thermal spread on the dermal layer of skin, reducing the risk of injury to surrounding tissue and structures. Therapeutic levels of heat delivered at intradermal temperatures that range from 39 to 53  C induce collagen contraction, neocollagenesis, and elastin uniformity, resulting in firmer, denser rejuvenated skin with restored elasticity. The initial wound healing response takes 3-4 weeks.

"It’s great for the patient who comes in and wants no down time, a little bit of tightening, and they want some global facial rejuvenation," Dr. Carniol said of the Pellevè system, which was cleared by the Food and Drug Administration in 2009 for the nonablative treatment of mild to moderate facial wrinkles and rhytids for Fitzpatrick skin types I-IV. The technology is contraindicated for patients with pacemakers, implantable cardioverter defibrillators, and any other implanted devices.

In one study, 93 patients were followed for 6 months after a single treatment with the Pellevè system. The response rate was determined by three independent, blinded assessors, including two facial plastic surgeons and one dermatologist (J. Drugs Dermatol. 2007;6:381-6). The response rates at 30, 90, and 180 days were 90.3%, 88.2%, and 87.1%, respectively.

In Dr. Carniol’s clinical experience, the ideal patients for the Pellevè system include those aged 35-60 years who present with modest to moderate laxity, but relatively elastic skin, moderate submental sagging, lax jaw lines and early jowls, moderate nasolabial folds, perioral and periorbital wrinkles, and/or relatively thin connective tissue layers. "You also want patients who aren’t that heavy," he said. "If someone is very overweight, the device is not going to work because the effect of all the excess tissue is too much."

Other poor candidates for the procedure include those with severely photodamaged skin, severe laxity or sagging, very deep wrinkles or muscle motion–induced rhytids, thick connective tissues, and/or unrealistic expectations. Post treatment, he said, "there is essentially no down time, which is one of the reasons that it’s such a great procedure, because your patients can take a break from work, come in, and return right to work."

His posttreatment instructions include washing the skin with tepid water and a gentle cleanser, use of nonirritating moisturizers, and use of sun block with UVA and UVB protection with an SPF of 30 or greater. The Pellevè treatment may be combined with fractionated resurfacing, but RF treatment "should be done at least 4 weeks prior to the laser treatment," he advised. "Pellevè may also be given with other treatments such as neurotoxins and fillers. Most physicians recommend this either at least 2 weeks prior to radiofrequency or at 1-2 weeks after injection after tissue reactions have subsided."

He also advised suspending the use of topical agents, which may cause erythema or irritation, for a week before and a week after Pellevè treatment; these agents include retinol/Retin-A (tretinoin)/isotretinoin, glycolic acid, and salicylic acid.

Dr. Carniol also discussed his experience with truSculpt (Cutera, Brisbane, Calif.), a monopolar RF device cleared for deep tissue heating and the temporary reduction in the appearance of cellulite. It features a large applicator that delivers energy 1.3-3 cm into the skin to targeted subcutaneous tissue before dispersing in underlying highly conductive fluids and tissues. The goal is for patients to be treated at the highest temperature that they can comfortably tolerate, typically between 42 and 46  C. Pulse durations of 4 minutes are recommended for each imprint. "Treatment should be uncomfortable, but not unbearable," he said. "Moderate hyperemia is expected and will persist for several hours."

The subcutaneous heating creates apoptosis, "a process whereby the cells resorb over a period of 3-12 weeks," explained Dr. Carniol. "It’s a very slow and gradual loss of fat cells compared with necrosis, which gives you instantaneous cell death and an acute inflammatory response and indurations."

The truSculpt device includes a proprietary contoured design to ensure uniform delivery and current. The electrode is available in four sizes: 15 cm², 25 cm², 30 cm², and 40 cm². This design "optimizes treatment uniformity over large exposure areas, which results in enhanced patient comfort and no hot spots or edge effects to cause pain," Dr. Carniol said.

Studies using before and after ultrasound images have demonstrated that the technology reduces treated areas of subcutaneous fat by up to 25%. "In general, I don’t think you see as much improvement with just one treatment," he noted. "I think it takes two to three treatments for best results."

In his clinical experience, the ideal patients for the procedure include those in generally good health with a body mass index between 22 and 28 kg/m² who have focal areas that they want reduced. The device is indicated for use on all Fitzpatrick skin types and tanned skin.

Dr. Carniol disclosed that he has given presentations for Ellman and Cutera, but said that he has no relevant financial interests in either company.

dbrunk@frontlinemedcom.com

LAS VEGAS – If a patient presents with eczema of the eyelids, or swollen eyelids that don’t respond to topical steroids, think about sending them for chemical testing, advised Dr. Janet M. Neigel.

"The eyelids are red and scaly, a little swollen, and it just never goes away," she said in an interview at the annual meeting of the American Academy of Cosmetic Surgery.

Courtesy Dr. Janet L. Neigel

Dr. Neigel, a cosmetic surgeon in West Orange, N.J., said that over the past 5 years, she has seen increasing numbers of patients present with eczema localized to the eyelids or eyeball area that recurs like pesky crabgrass.

"I treat them with topical steroids," Dr. Neigel said. "It will get better, but it always comes back. Some of this is seasonal. It may only happen in the winter, when the air is drier and their skin tends to get drier. In others it can be all year long," she said. "It seems to be more common in women, but I see men with this condition, too. In men, it tends to present as a reddish eye and tearing," she noted.

In the majority of cases, the culprit turns out to be an allergy to chemicals including gold, nickel, tin, rubber, preservatives in shampoos and laundry detergent, and formaldehyde resin, which is used in nail polish. "There was one patient who was allergic to the preservative in eyedrops," Dr. Neigel recalled. "She was on several different eyedrops trying to treat the swollen eye area, and it was just making the condition worse."

Another patient’s eczema cleared only after she removed her wedding ring, Dr. Neigel said. "So she couldn’t wear any gold jewelry. In somebody else it was tin and nickel, so she couldn’t wear any cheap jewelry."

Ointments commonly used for cosmetic procedures also can cause trouble. "There is cross-reactivity between neomycin, tobramycin, and Neosporin," Dr. Neigel said. "One patient was applying Neosporin every time she bumped herself on different parts of her body, and her eyelids were the only things flaring up."

Dr. Neigel speculated that the reaction in such cases is localized to the eyelid because "it’s the thinnest skin in the body. It’s the most sensitive, and for some reason, the patients I’m seeing only have reactions there," she noted. So, for patients with allergic conjunctivitis or tearing for a contact dermatitis–type presentation around the eyeball or the eyelids, send them for chemical testing, she advised. "There’s a good chance you might clear things up and figure out what they’re truly reacting to – get to the source instead of just treating the problem symptomatically," she said.

Dr. Neigel said she had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

LAS VEGAS – If a patient presents with eczema of the eyelids, or swollen eyelids that don’t respond to topical steroids, think about sending them for chemical testing, advised Dr. Janet M. Neigel.

"The eyelids are red and scaly, a little swollen, and it just never goes away," she said in an interview at the annual meeting of the American Academy of Cosmetic Surgery.

Courtesy Dr. Janet L. Neigel

Dr. Neigel, a cosmetic surgeon in West Orange, N.J., said that over the past 5 years, she has seen increasing numbers of patients present with eczema localized to the eyelids or eyeball area that recurs like pesky crabgrass.

"I treat them with topical steroids," Dr. Neigel said. "It will get better, but it always comes back. Some of this is seasonal. It may only happen in the winter, when the air is drier and their skin tends to get drier. In others it can be all year long," she said. "It seems to be more common in women, but I see men with this condition, too. In men, it tends to present as a reddish eye and tearing," she noted.

In the majority of cases, the culprit turns out to be an allergy to chemicals including gold, nickel, tin, rubber, preservatives in shampoos and laundry detergent, and formaldehyde resin, which is used in nail polish. "There was one patient who was allergic to the preservative in eyedrops," Dr. Neigel recalled. "She was on several different eyedrops trying to treat the swollen eye area, and it was just making the condition worse."

Another patient’s eczema cleared only after she removed her wedding ring, Dr. Neigel said. "So she couldn’t wear any gold jewelry. In somebody else it was tin and nickel, so she couldn’t wear any cheap jewelry."

Ointments commonly used for cosmetic procedures also can cause trouble. "There is cross-reactivity between neomycin, tobramycin, and Neosporin," Dr. Neigel said. "One patient was applying Neosporin every time she bumped herself on different parts of her body, and her eyelids were the only things flaring up."

Dr. Neigel speculated that the reaction in such cases is localized to the eyelid because "it’s the thinnest skin in the body. It’s the most sensitive, and for some reason, the patients I’m seeing only have reactions there," she noted. So, for patients with allergic conjunctivitis or tearing for a contact dermatitis–type presentation around the eyeball or the eyelids, send them for chemical testing, she advised. "There’s a good chance you might clear things up and figure out what they’re truly reacting to – get to the source instead of just treating the problem symptomatically," she said.

Dr. Neigel said she had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

LAS VEGAS – If a patient presents with eczema of the eyelids, or swollen eyelids that don’t respond to topical steroids, think about sending them for chemical testing, advised Dr. Janet M. Neigel.

"The eyelids are red and scaly, a little swollen, and it just never goes away," she said in an interview at the annual meeting of the American Academy of Cosmetic Surgery.

Courtesy Dr. Janet L. Neigel

Dr. Neigel, a cosmetic surgeon in West Orange, N.J., said that over the past 5 years, she has seen increasing numbers of patients present with eczema localized to the eyelids or eyeball area that recurs like pesky crabgrass.

"I treat them with topical steroids," Dr. Neigel said. "It will get better, but it always comes back. Some of this is seasonal. It may only happen in the winter, when the air is drier and their skin tends to get drier. In others it can be all year long," she said. "It seems to be more common in women, but I see men with this condition, too. In men, it tends to present as a reddish eye and tearing," she noted.

In the majority of cases, the culprit turns out to be an allergy to chemicals including gold, nickel, tin, rubber, preservatives in shampoos and laundry detergent, and formaldehyde resin, which is used in nail polish. "There was one patient who was allergic to the preservative in eyedrops," Dr. Neigel recalled. "She was on several different eyedrops trying to treat the swollen eye area, and it was just making the condition worse."

Another patient’s eczema cleared only after she removed her wedding ring, Dr. Neigel said. "So she couldn’t wear any gold jewelry. In somebody else it was tin and nickel, so she couldn’t wear any cheap jewelry."

Ointments commonly used for cosmetic procedures also can cause trouble. "There is cross-reactivity between neomycin, tobramycin, and Neosporin," Dr. Neigel said. "One patient was applying Neosporin every time she bumped herself on different parts of her body, and her eyelids were the only things flaring up."

Dr. Neigel speculated that the reaction in such cases is localized to the eyelid because "it’s the thinnest skin in the body. It’s the most sensitive, and for some reason, the patients I’m seeing only have reactions there," she noted. So, for patients with allergic conjunctivitis or tearing for a contact dermatitis–type presentation around the eyeball or the eyelids, send them for chemical testing, she advised. "There’s a good chance you might clear things up and figure out what they’re truly reacting to – get to the source instead of just treating the problem symptomatically," she said.

Dr. Neigel said she had no relevant financial disclosures.

dbrunk@frontlinemedcom.com

LAS VEGAS – Periorbital fillers are an attractive option to the myriad of surgical face-lift procedures available to patients seeking skin rejuvenation, according to Dr. Janet M. Neigel.

"The advantages to using fillers for periorbital rejuvenation are that they are a lunchtime treatment, there’s minimal risk, it results in a natural appearance, it’s minimally invasive, and it’s a good nonsurgical alternative, especially if a patient is not ready for surgery," Dr. Neigel said at the annual meeting of the American Academy of Cosmetic Surgery. "It’s also a great way to get to know your patients before they undergo a bigger procedure."

According to statistics from the American Society of Plastic Surgeons, clinicians performed 12.2 million nonsurgical cosmetic surgical procedures in the United States in 2011. Of these, 1.9 million were fillers.

"With aging there are certain structural changes to the face, including dermal thinning, fat loss, prolapse, redistribution, and skeletal bone remodeling," said Dr. Neigel, a West Orange, N.J.–based cosmetic surgeon who specializes in plastic and reconstructive surgery of the eyes and face. "The natural oval, upside down egg shape of the face changes more to a peanut-shaped face."

Prior to using any fillers, Dr. Neigel said she examines the intended treatment area of skin for hyperpigmentation and points out the relevant spots to patients. "Sometimes patients think that the use of fillers is going to make them have normal skin," she said. "With fillers you’ll improve the shadows, but you’re not going to be able to improve the hyperpigmentation."

Her go-to products for periorbital rejuvenation include the hyaluronic acids Juvederm, Restylane, and Belotero as well as the stimulatory fillers Sculptra (poly-l-lactic acid) and Radiesse (calcium hydroxylapatite). "Crow’s feet are difficult to deal with if they don’t respond completely to your neuromodulator of choice," Dr. Neigel noted. "Botox, Dysport, or Xeomin are the first injections of choice, but I have recently been using Belotero and have been very impressed with how it can improve the eyelid area. It’s used superficially in a layered manner."

When treating the lower-lid tear trough Dr. Neigel said she makes it a point to inject deep just over the periosteum and more inferiorly on the cheek. "Many times if you just inject above the orbital rim, you’re not going to address the full defect," she said. "Oftentimes you need to inject in multiple tissue planes. I use Restylane and Belotero around the eyes, and I inject in a retrograde fashion. I’m always nervous that Juvederm is going to cause too much water to be brought in and too much swelling. I reserve Juvederm for the lower face."

When treating the midface region, Dr. Neigel said that she most often uses Sculptra. "The goal in this area is to volumize the deep medial cheek fat, try to get anterior projection of the cheek and effacement of the lower-lid bags," she said. "We’re reflating the tissue, fighting some gravity, and filling Ristow’s space."

In her clinical experience, the most common complications from using stimulator fillers are ecchymosis and edema. "I have not seen any infections," she said. "I have seen several granulomas, papules, and nodules. If you get lumpiness, you can massage and most of the time it goes away, or you can use hyaluronidase. You can get a Tyndall effect, but I have not seen it in this area. You can also get overcorrection or undercorrection."

When nodules occur, "most of the time they’re not visible," she added. "You can palpate them, but as long as they’re not visible I leave them be."

Dr. Neigel disclosed that she is a consultant for Allergan, Medicis, and Valeant.

dbrunk@frontlinemedcom.com

LAS VEGAS – Periorbital fillers are an attractive option to the myriad of surgical face-lift procedures available to patients seeking skin rejuvenation, according to Dr. Janet M. Neigel.

"The advantages to using fillers for periorbital rejuvenation are that they are a lunchtime treatment, there’s minimal risk, it results in a natural appearance, it’s minimally invasive, and it’s a good nonsurgical alternative, especially if a patient is not ready for surgery," Dr. Neigel said at the annual meeting of the American Academy of Cosmetic Surgery. "It’s also a great way to get to know your patients before they undergo a bigger procedure."

According to statistics from the American Society of Plastic Surgeons, clinicians performed 12.2 million nonsurgical cosmetic surgical procedures in the United States in 2011. Of these, 1.9 million were fillers.

"With aging there are certain structural changes to the face, including dermal thinning, fat loss, prolapse, redistribution, and skeletal bone remodeling," said Dr. Neigel, a West Orange, N.J.–based cosmetic surgeon who specializes in plastic and reconstructive surgery of the eyes and face. "The natural oval, upside down egg shape of the face changes more to a peanut-shaped face."

Prior to using any fillers, Dr. Neigel said she examines the intended treatment area of skin for hyperpigmentation and points out the relevant spots to patients. "Sometimes patients think that the use of fillers is going to make them have normal skin," she said. "With fillers you’ll improve the shadows, but you’re not going to be able to improve the hyperpigmentation."

Her go-to products for periorbital rejuvenation include the hyaluronic acids Juvederm, Restylane, and Belotero as well as the stimulatory fillers Sculptra (poly-l-lactic acid) and Radiesse (calcium hydroxylapatite). "Crow’s feet are difficult to deal with if they don’t respond completely to your neuromodulator of choice," Dr. Neigel noted. "Botox, Dysport, or Xeomin are the first injections of choice, but I have recently been using Belotero and have been very impressed with how it can improve the eyelid area. It’s used superficially in a layered manner."

When treating the lower-lid tear trough Dr. Neigel said she makes it a point to inject deep just over the periosteum and more inferiorly on the cheek. "Many times if you just inject above the orbital rim, you’re not going to address the full defect," she said. "Oftentimes you need to inject in multiple tissue planes. I use Restylane and Belotero around the eyes, and I inject in a retrograde fashion. I’m always nervous that Juvederm is going to cause too much water to be brought in and too much swelling. I reserve Juvederm for the lower face."

When treating the midface region, Dr. Neigel said that she most often uses Sculptra. "The goal in this area is to volumize the deep medial cheek fat, try to get anterior projection of the cheek and effacement of the lower-lid bags," she said. "We’re reflating the tissue, fighting some gravity, and filling Ristow’s space."

In her clinical experience, the most common complications from using stimulator fillers are ecchymosis and edema. "I have not seen any infections," she said. "I have seen several granulomas, papules, and nodules. If you get lumpiness, you can massage and most of the time it goes away, or you can use hyaluronidase. You can get a Tyndall effect, but I have not seen it in this area. You can also get overcorrection or undercorrection."

When nodules occur, "most of the time they’re not visible," she added. "You can palpate them, but as long as they’re not visible I leave them be."

Dr. Neigel disclosed that she is a consultant for Allergan, Medicis, and Valeant.

dbrunk@frontlinemedcom.com

LAS VEGAS – Periorbital fillers are an attractive option to the myriad of surgical face-lift procedures available to patients seeking skin rejuvenation, according to Dr. Janet M. Neigel.

"The advantages to using fillers for periorbital rejuvenation are that they are a lunchtime treatment, there’s minimal risk, it results in a natural appearance, it’s minimally invasive, and it’s a good nonsurgical alternative, especially if a patient is not ready for surgery," Dr. Neigel said at the annual meeting of the American Academy of Cosmetic Surgery. "It’s also a great way to get to know your patients before they undergo a bigger procedure."

According to statistics from the American Society of Plastic Surgeons, clinicians performed 12.2 million nonsurgical cosmetic surgical procedures in the United States in 2011. Of these, 1.9 million were fillers.

"With aging there are certain structural changes to the face, including dermal thinning, fat loss, prolapse, redistribution, and skeletal bone remodeling," said Dr. Neigel, a West Orange, N.J.–based cosmetic surgeon who specializes in plastic and reconstructive surgery of the eyes and face. "The natural oval, upside down egg shape of the face changes more to a peanut-shaped face."

Prior to using any fillers, Dr. Neigel said she examines the intended treatment area of skin for hyperpigmentation and points out the relevant spots to patients. "Sometimes patients think that the use of fillers is going to make them have normal skin," she said. "With fillers you’ll improve the shadows, but you’re not going to be able to improve the hyperpigmentation."

Her go-to products for periorbital rejuvenation include the hyaluronic acids Juvederm, Restylane, and Belotero as well as the stimulatory fillers Sculptra (poly-l-lactic acid) and Radiesse (calcium hydroxylapatite). "Crow’s feet are difficult to deal with if they don’t respond completely to your neuromodulator of choice," Dr. Neigel noted. "Botox, Dysport, or Xeomin are the first injections of choice, but I have recently been using Belotero and have been very impressed with how it can improve the eyelid area. It’s used superficially in a layered manner."

When treating the lower-lid tear trough Dr. Neigel said she makes it a point to inject deep just over the periosteum and more inferiorly on the cheek. "Many times if you just inject above the orbital rim, you’re not going to address the full defect," she said. "Oftentimes you need to inject in multiple tissue planes. I use Restylane and Belotero around the eyes, and I inject in a retrograde fashion. I’m always nervous that Juvederm is going to cause too much water to be brought in and too much swelling. I reserve Juvederm for the lower face."

When treating the midface region, Dr. Neigel said that she most often uses Sculptra. "The goal in this area is to volumize the deep medial cheek fat, try to get anterior projection of the cheek and effacement of the lower-lid bags," she said. "We’re reflating the tissue, fighting some gravity, and filling Ristow’s space."

In her clinical experience, the most common complications from using stimulator fillers are ecchymosis and edema. "I have not seen any infections," she said. "I have seen several granulomas, papules, and nodules. If you get lumpiness, you can massage and most of the time it goes away, or you can use hyaluronidase. You can get a Tyndall effect, but I have not seen it in this area. You can also get overcorrection or undercorrection."

When nodules occur, "most of the time they’re not visible," she added. "You can palpate them, but as long as they’re not visible I leave them be."

Dr. Neigel disclosed that she is a consultant for Allergan, Medicis, and Valeant.

dbrunk@frontlinemedcom.com

LAS VEGAS  – Enhancing your online reputation is a tricky business, an industry that Robert Baxter said attracts a lot of sharks.

"A lot of people in this field are not very good at what they do," Mr. Baxter said at the annual meeting of the American Academy of Cosmetic Surgery. "They’re going to take your money and promise things they can’t deliver. Be careful."

It can also be expensive, especially when it comes to repairing your reputation. That part of the business "is so expensive that I personally stay out of it," said Mr. Baxter, a Miami Beach–based consultant who is widely considered a leading expert in physician reputation management.

"If you have a big problem, like a situation with a state medical board or negative appearance on a news station, it could cost $5,000-$10,000 per month for a minimum of 6 months to push the negative items down," he said. "There are no tried and true methods for what you do each time, either. It’s a case by case situation. For a posting on a review site, it helps if you can figure out who that patient is and get an idea of the psychology of how much trouble that person could actually cause."

To have your reputation look good online, Mr. Baxter recommended standardizing, claiming, and optimizing pages about you on the Web, including your Google Places page, your pages on review sites, your own practice website, your YouTube page, and your LinkedIn account. That way, the online information about you appears cohesive, "and you have a better opportunity to rank and control more of your name space," he explained.

What’s more, you should go after the increasing number of mobile visitors because "targeting mobile users is one of the biggest goals for both Apple and Google," Mr. Baxter said.

Another way to enhance your reputation is to enlist the aid of patients who are willing to write a review of your practice on sites such as Yelp.com or RateMDs.com. It helps to have patients post positive reviews and comments on the sites they hold accounts with. "If someone is an active Yelp user, they should post on Yelp, while someone who has a Google Plus account should post on Google," he noted.

According to Mr. Baxter, Google is moving toward the concept of the "semantic web," whereby the search engine works more like the human brain so that it "knows" what you might be looking for. "It’s no longer just about links as it relates to reviews and rankings," commented Mr. Baxter. "It’s about what’s being said about you and what’s written online in general."

To get a sense of your current online reputation, he recommended typing your name and "reviews" into the subject line of the search engine. "That’s going to give you a good representation of what your name space looks like as it relates to your reputation," he said.

Mr. Baxter also advises clients to use marquee phrases. "So if, for instance, you’re a dermatologist in San Diego, you should search for San Diego dermatologist to see both how you are ranking and how your reputation looks alongside your listing," he said. "You should also pay close attention to how your competitors look, because if someone is doing really well with reviews, you want to emulate what they’re doing."

Mr. Baxter said he had no relevant financial conflicts to disclose.

d.brunk@elsevier.com

LAS VEGAS  – Enhancing your online reputation is a tricky business, an industry that Robert Baxter said attracts a lot of sharks.

"A lot of people in this field are not very good at what they do," Mr. Baxter said at the annual meeting of the American Academy of Cosmetic Surgery. "They’re going to take your money and promise things they can’t deliver. Be careful."

It can also be expensive, especially when it comes to repairing your reputation. That part of the business "is so expensive that I personally stay out of it," said Mr. Baxter, a Miami Beach–based consultant who is widely considered a leading expert in physician reputation management.

"If you have a big problem, like a situation with a state medical board or negative appearance on a news station, it could cost $5,000-$10,000 per month for a minimum of 6 months to push the negative items down," he said. "There are no tried and true methods for what you do each time, either. It’s a case by case situation. For a posting on a review site, it helps if you can figure out who that patient is and get an idea of the psychology of how much trouble that person could actually cause."

To have your reputation look good online, Mr. Baxter recommended standardizing, claiming, and optimizing pages about you on the Web, including your Google Places page, your pages on review sites, your own practice website, your YouTube page, and your LinkedIn account. That way, the online information about you appears cohesive, "and you have a better opportunity to rank and control more of your name space," he explained.

What’s more, you should go after the increasing number of mobile visitors because "targeting mobile users is one of the biggest goals for both Apple and Google," Mr. Baxter said.

Another way to enhance your reputation is to enlist the aid of patients who are willing to write a review of your practice on sites such as Yelp.com or RateMDs.com. It helps to have patients post positive reviews and comments on the sites they hold accounts with. "If someone is an active Yelp user, they should post on Yelp, while someone who has a Google Plus account should post on Google," he noted.

According to Mr. Baxter, Google is moving toward the concept of the "semantic web," whereby the search engine works more like the human brain so that it "knows" what you might be looking for. "It’s no longer just about links as it relates to reviews and rankings," commented Mr. Baxter. "It’s about what’s being said about you and what’s written online in general."

To get a sense of your current online reputation, he recommended typing your name and "reviews" into the subject line of the search engine. "That’s going to give you a good representation of what your name space looks like as it relates to your reputation," he said.

Mr. Baxter also advises clients to use marquee phrases. "So if, for instance, you’re a dermatologist in San Diego, you should search for San Diego dermatologist to see both how you are ranking and how your reputation looks alongside your listing," he said. "You should also pay close attention to how your competitors look, because if someone is doing really well with reviews, you want to emulate what they’re doing."

Mr. Baxter said he had no relevant financial conflicts to disclose.

d.brunk@elsevier.com

LAS VEGAS  – Enhancing your online reputation is a tricky business, an industry that Robert Baxter said attracts a lot of sharks.

"A lot of people in this field are not very good at what they do," Mr. Baxter said at the annual meeting of the American Academy of Cosmetic Surgery. "They’re going to take your money and promise things they can’t deliver. Be careful."

It can also be expensive, especially when it comes to repairing your reputation. That part of the business "is so expensive that I personally stay out of it," said Mr. Baxter, a Miami Beach–based consultant who is widely considered a leading expert in physician reputation management.

"If you have a big problem, like a situation with a state medical board or negative appearance on a news station, it could cost $5,000-$10,000 per month for a minimum of 6 months to push the negative items down," he said. "There are no tried and true methods for what you do each time, either. It’s a case by case situation. For a posting on a review site, it helps if you can figure out who that patient is and get an idea of the psychology of how much trouble that person could actually cause."

To have your reputation look good online, Mr. Baxter recommended standardizing, claiming, and optimizing pages about you on the Web, including your Google Places page, your pages on review sites, your own practice website, your YouTube page, and your LinkedIn account. That way, the online information about you appears cohesive, "and you have a better opportunity to rank and control more of your name space," he explained.

What’s more, you should go after the increasing number of mobile visitors because "targeting mobile users is one of the biggest goals for both Apple and Google," Mr. Baxter said.

Another way to enhance your reputation is to enlist the aid of patients who are willing to write a review of your practice on sites such as Yelp.com or RateMDs.com. It helps to have patients post positive reviews and comments on the sites they hold accounts with. "If someone is an active Yelp user, they should post on Yelp, while someone who has a Google Plus account should post on Google," he noted.

According to Mr. Baxter, Google is moving toward the concept of the "semantic web," whereby the search engine works more like the human brain so that it "knows" what you might be looking for. "It’s no longer just about links as it relates to reviews and rankings," commented Mr. Baxter. "It’s about what’s being said about you and what’s written online in general."

To get a sense of your current online reputation, he recommended typing your name and "reviews" into the subject line of the search engine. "That’s going to give you a good representation of what your name space looks like as it relates to your reputation," he said.

Mr. Baxter also advises clients to use marquee phrases. "So if, for instance, you’re a dermatologist in San Diego, you should search for San Diego dermatologist to see both how you are ranking and how your reputation looks alongside your listing," he said. "You should also pay close attention to how your competitors look, because if someone is doing really well with reviews, you want to emulate what they’re doing."

Mr. Baxter said he had no relevant financial conflicts to disclose.

d.brunk@elsevier.com

LAS VEGAS – The 595-nm pulsed dye laser, which allows for the application of 8 micropulses instead of a single pulse is one go-to device for treating vascular lesions, according to Dr. Melanie Palm.

"This allows me to use higher fluences without some of that eggplant purple discoloration or purpura that I would get if I used higher fluences in earlier generations of this laser," Dr. Palm said at the annual meeting of the American Academy of Cosmetic Surgery.

For example, when treating nasal telangiectasias, Dr. Palm said she sets the parameters to a fluence of 13-15 J/cm², a pulse width of 40 milliseconds, and a spot size of 7 mm. "Using this new platform, I don’t get any of the purpura that you would expect with the more traditional 585-nm pulsed dye laser," said Dr. Palm, a dermatologist in Solana Beach, Calif.

Dr. Palm said she also has used the 595-nm pulsed dye laser (PDL) to treat rosacea, cherry angiomas, venous lakes, vascular malformations, postinflammatory erythema, striae distensae, scars, and purpura. "I will often combine treatments," she continued. For scars, she may combine 5-fluorouracil and intralesional Kenalog (triamcinolone), and immediately treat with the 595-nm PDL set to a fluence of 8 J/cm², a pulse width of 10 milliseconds, and a spot size of 7 mm. For recalcitrant warts, she will often try intralesional bleomycin combined with the 595-nm PDL set to a fluence of 1-15 J/cm², a pulse width of 1.5 milliseconds, and a spot size of 7 mm. "If the 595-nm PDL is the only laser in your office, you can use it to treat solar lentigines and other pigmentary disorders with some success," Dr. Palm said. "I also use it a lot for posttreatment bruising."

Intense pulsed light (IPL) is another technology Dr. Palm said she uses to treat vascular lesions. When discussing this technology with her patients, "I set the expectation that this is going to involve multiple treatments," Dr. Palm said. "I’ll often show them right after treatment that the vessels have gone into vasospasm. They have disappeared, but they will come back, and it will be several weeks before they see improvement."

Dr. Palm said she typically uses lidocaine cream as a numbing agent to improve patient comfort prior to IPL procedures. "But if patients want a stronger numbing agent, I mix lidocaine with tetracaine, which has a tendency to cause flushing," she said. "You can also use a hair dryer to aggravate erythema on the face prior to treatment."

Dr. Palm said she often uses the 515-nm filter with IPL energy applied in triple pulses to treat facial erythema. For facial telangiectasias, she typically uses the 560-nm filter with IPL energy applied in double pulses. "For stubborn spots, I switch to a smaller treatment hand piece, which creates higher fluence," she said.

Dr. Palm said she advises clinicians to be aggressive in treating postoperative scars. "If I see some redness, I’ll often treat as early as 1 month after treatment, using either a PDL or an IPL," she said. If she uses a PDL, she sets it to a fluence of 7-10 J/cm², a pulse width of 10 milliseconds, and a spot size of 7 mm. If she uses an IPL, she employs a 560-nm filter, and sets the device to a fluence of 16-18 J/cm² and a pulse width of 4 milliseconds.

To treat postprocedural bruising, Dr. Palm said she may use a PDL set to a fluence of 6 J/cm², a pulse width of 6 milliseconds, and a spot size of 10 mm. If she opts to treat the bruising with an IPL, she employs a 560-nm filter and sets the device to a fluence of 13-15 J/cm² and a pulse width of 4 milliseconds, and applies it in a double-pulse fashion. "You want to titrate the fluence inversely to the degree of bruising," Dr. Palm advised. "If you have an intense bruise, you want to decrease the fluence. If it’s a light bruise, you want to use higher fluences," she said. "I typically use a single pulse. You want to avoid pulse stacking because you can make the bruising worse. I don’t just treat where the bruise is. I treat within a centimeter around the bruised area as well."

Dr. Palm also discussed her experience using the Q-switched Nd:YAG double-frequency 532-nm laser as "a peel" to treat facial redness. "It’s usually a single-pass treatment that uses a double-frequency 1,064 Nd:YAG platform," she said. "I typically use an 8-mm hand piece set to a fluence of 3.5-5 J/cm². Results are usually apparent within one to two treatments," she noted.

Dr. Palm disclosed that she is a speaker for Valeant, Medicis, and Lumenis. She is also a consultant for Lutronic.

d.brunk@elsevier.com

LAS VEGAS – The 595-nm pulsed dye laser, which allows for the application of 8 micropulses instead of a single pulse is one go-to device for treating vascular lesions, according to Dr. Melanie Palm.

"This allows me to use higher fluences without some of that eggplant purple discoloration or purpura that I would get if I used higher fluences in earlier generations of this laser," Dr. Palm said at the annual meeting of the American Academy of Cosmetic Surgery.

For example, when treating nasal telangiectasias, Dr. Palm said she sets the parameters to a fluence of 13-15 J/cm², a pulse width of 40 milliseconds, and a spot size of 7 mm. "Using this new platform, I don’t get any of the purpura that you would expect with the more traditional 585-nm pulsed dye laser," said Dr. Palm, a dermatologist in Solana Beach, Calif.

Dr. Palm said she also has used the 595-nm pulsed dye laser (PDL) to treat rosacea, cherry angiomas, venous lakes, vascular malformations, postinflammatory erythema, striae distensae, scars, and purpura. "I will often combine treatments," she continued. For scars, she may combine 5-fluorouracil and intralesional Kenalog (triamcinolone), and immediately treat with the 595-nm PDL set to a fluence of 8 J/cm², a pulse width of 10 milliseconds, and a spot size of 7 mm. For recalcitrant warts, she will often try intralesional bleomycin combined with the 595-nm PDL set to a fluence of 1-15 J/cm², a pulse width of 1.5 milliseconds, and a spot size of 7 mm. "If the 595-nm PDL is the only laser in your office, you can use it to treat solar lentigines and other pigmentary disorders with some success," Dr. Palm said. "I also use it a lot for posttreatment bruising."

Intense pulsed light (IPL) is another technology Dr. Palm said she uses to treat vascular lesions. When discussing this technology with her patients, "I set the expectation that this is going to involve multiple treatments," Dr. Palm said. "I’ll often show them right after treatment that the vessels have gone into vasospasm. They have disappeared, but they will come back, and it will be several weeks before they see improvement."

Dr. Palm said she typically uses lidocaine cream as a numbing agent to improve patient comfort prior to IPL procedures. "But if patients want a stronger numbing agent, I mix lidocaine with tetracaine, which has a tendency to cause flushing," she said. "You can also use a hair dryer to aggravate erythema on the face prior to treatment."

Dr. Palm said she often uses the 515-nm filter with IPL energy applied in triple pulses to treat facial erythema. For facial telangiectasias, she typically uses the 560-nm filter with IPL energy applied in double pulses. "For stubborn spots, I switch to a smaller treatment hand piece, which creates higher fluence," she said.

Dr. Palm said she advises clinicians to be aggressive in treating postoperative scars. "If I see some redness, I’ll often treat as early as 1 month after treatment, using either a PDL or an IPL," she said. If she uses a PDL, she sets it to a fluence of 7-10 J/cm², a pulse width of 10 milliseconds, and a spot size of 7 mm. If she uses an IPL, she employs a 560-nm filter, and sets the device to a fluence of 16-18 J/cm² and a pulse width of 4 milliseconds.

To treat postprocedural bruising, Dr. Palm said she may use a PDL set to a fluence of 6 J/cm², a pulse width of 6 milliseconds, and a spot size of 10 mm. If she opts to treat the bruising with an IPL, she employs a 560-nm filter and sets the device to a fluence of 13-15 J/cm² and a pulse width of 4 milliseconds, and applies it in a double-pulse fashion. "You want to titrate the fluence inversely to the degree of bruising," Dr. Palm advised. "If you have an intense bruise, you want to decrease the fluence. If it’s a light bruise, you want to use higher fluences," she said. "I typically use a single pulse. You want to avoid pulse stacking because you can make the bruising worse. I don’t just treat where the bruise is. I treat within a centimeter around the bruised area as well."

Dr. Palm also discussed her experience using the Q-switched Nd:YAG double-frequency 532-nm laser as "a peel" to treat facial redness. "It’s usually a single-pass treatment that uses a double-frequency 1,064 Nd:YAG platform," she said. "I typically use an 8-mm hand piece set to a fluence of 3.5-5 J/cm². Results are usually apparent within one to two treatments," she noted.

Dr. Palm disclosed that she is a speaker for Valeant, Medicis, and Lumenis. She is also a consultant for Lutronic.

d.brunk@elsevier.com

LAS VEGAS – The 595-nm pulsed dye laser, which allows for the application of 8 micropulses instead of a single pulse is one go-to device for treating vascular lesions, according to Dr. Melanie Palm.

"This allows me to use higher fluences without some of that eggplant purple discoloration or purpura that I would get if I used higher fluences in earlier generations of this laser," Dr. Palm said at the annual meeting of the American Academy of Cosmetic Surgery.

For example, when treating nasal telangiectasias, Dr. Palm said she sets the parameters to a fluence of 13-15 J/cm², a pulse width of 40 milliseconds, and a spot size of 7 mm. "Using this new platform, I don’t get any of the purpura that you would expect with the more traditional 585-nm pulsed dye laser," said Dr. Palm, a dermatologist in Solana Beach, Calif.

Dr. Palm said she also has used the 595-nm pulsed dye laser (PDL) to treat rosacea, cherry angiomas, venous lakes, vascular malformations, postinflammatory erythema, striae distensae, scars, and purpura. "I will often combine treatments," she continued. For scars, she may combine 5-fluorouracil and intralesional Kenalog (triamcinolone), and immediately treat with the 595-nm PDL set to a fluence of 8 J/cm², a pulse width of 10 milliseconds, and a spot size of 7 mm. For recalcitrant warts, she will often try intralesional bleomycin combined with the 595-nm PDL set to a fluence of 1-15 J/cm², a pulse width of 1.5 milliseconds, and a spot size of 7 mm. "If the 595-nm PDL is the only laser in your office, you can use it to treat solar lentigines and other pigmentary disorders with some success," Dr. Palm said. "I also use it a lot for posttreatment bruising."

Intense pulsed light (IPL) is another technology Dr. Palm said she uses to treat vascular lesions. When discussing this technology with her patients, "I set the expectation that this is going to involve multiple treatments," Dr. Palm said. "I’ll often show them right after treatment that the vessels have gone into vasospasm. They have disappeared, but they will come back, and it will be several weeks before they see improvement."

Dr. Palm said she typically uses lidocaine cream as a numbing agent to improve patient comfort prior to IPL procedures. "But if patients want a stronger numbing agent, I mix lidocaine with tetracaine, which has a tendency to cause flushing," she said. "You can also use a hair dryer to aggravate erythema on the face prior to treatment."

Dr. Palm said she often uses the 515-nm filter with IPL energy applied in triple pulses to treat facial erythema. For facial telangiectasias, she typically uses the 560-nm filter with IPL energy applied in double pulses. "For stubborn spots, I switch to a smaller treatment hand piece, which creates higher fluence," she said.

Dr. Palm said she advises clinicians to be aggressive in treating postoperative scars. "If I see some redness, I’ll often treat as early as 1 month after treatment, using either a PDL or an IPL," she said. If she uses a PDL, she sets it to a fluence of 7-10 J/cm², a pulse width of 10 milliseconds, and a spot size of 7 mm. If she uses an IPL, she employs a 560-nm filter, and sets the device to a fluence of 16-18 J/cm² and a pulse width of 4 milliseconds.

To treat postprocedural bruising, Dr. Palm said she may use a PDL set to a fluence of 6 J/cm², a pulse width of 6 milliseconds, and a spot size of 10 mm. If she opts to treat the bruising with an IPL, she employs a 560-nm filter and sets the device to a fluence of 13-15 J/cm² and a pulse width of 4 milliseconds, and applies it in a double-pulse fashion. "You want to titrate the fluence inversely to the degree of bruising," Dr. Palm advised. "If you have an intense bruise, you want to decrease the fluence. If it’s a light bruise, you want to use higher fluences," she said. "I typically use a single pulse. You want to avoid pulse stacking because you can make the bruising worse. I don’t just treat where the bruise is. I treat within a centimeter around the bruised area as well."

Dr. Palm also discussed her experience using the Q-switched Nd:YAG double-frequency 532-nm laser as "a peel" to treat facial redness. "It’s usually a single-pass treatment that uses a double-frequency 1,064 Nd:YAG platform," she said. "I typically use an 8-mm hand piece set to a fluence of 3.5-5 J/cm². Results are usually apparent within one to two treatments," she noted.

Dr. Palm disclosed that she is a speaker for Valeant, Medicis, and Lumenis. She is also a consultant for Lutronic.

d.brunk@elsevier.com

LAS VEGAS – Do your receptionists, patient coordinators, and other staff members represent you and your practice well? If not, it might be time for you to remind them that their role comes down to supporting you.

"Not knowing who’s on your team is a common marketing mistake," Catherine Maley said at the annual meeting of the American Academy of Cosmetic Surgery. "Nothing is more important in a cosmetic dermatology practice than having the right team in place. Your team is going to make or break your practice, because they are going to spend more time with your patients than you are."

Your staff must represent and promote you as the best choice, Ms. Maley said. "They have to embrace aesthetics," she emphasized. "I’ve been in offices where I’ve heard the receptionist say, ‘I would never get Botox.’ I have also heard a patient care coordinator say, ‘Just so you know, that’s not his best procedure. I would probably go somewhere else for that.’ "

Ms. Maley, a marketing strategist with Sausalito, Calif.–based Cosmetic Image Marketing, said that clinicians can find out which of their staff are true team players by staging a "refer a friend" contest in January or September, which are traditionally slow months for cosmetic dermatology practices. For the contest, employees have 30 days to distribute referral cards to family, friends, and other people in their social network. "At the end of 30 days, have a party and the employee who brings in the most referrals wins a prize – maybe an iPad or cash," Ms. Maley said. "Those who gave you the most referrals you know are on your team. Those who never participated aren’t."

Ms. Maley noted several other common mistakes clinicians make in marketing their practices, including:

• Ignoring your patients. Indifference "costs you, and it allows the gate to be open for your competitors," said Ms. Maley, who is also author of the book "Your Aesthetic Practice: What Your Patients Are Saying" (Sausalito: Cosmetic Imaging Marketing, 2011). "You have a captive market of aging baby boomers, so you want to keep them," she said. "For example, let’s say a patient shows up for a simple peel procedure or to buy a product. If they like what they got, they’re likely to start working their way up to injectables, laser procedures, or skin-tightening procedures. Keep them coming with messages by direct mail, e-mail, and social media," she said.

Although the Internet is fast and easy, don’t put all your eggs in that basket, Ms. Maley added. "You are missing out on half the patients who aren’t reading their e-mail and who can’t get past a computer firewall at work." Direct mail, she continued, offers an opportunity for one-on-one communication with the patient, "which is golden." Face time also builds trust. "The more face time you have with patients, the more they feel like they know you," she said.

• Assuming your patients will refer. Ms. Maley estimated that almost everyone knows about 150 people in their general geographic area, including service providers, family, friends, colleagues, and neighbors. "What if each patient referred one person to you?" she asked. "That could double your patient database. It’s worth asking patients who know you, like you, and trust you to refer at least one person to you."

While asking for referrals may seem awkward for some, she recommended displaying a sign in your waiting room that reads: "We love you as a patient. We would love to have more patients just like you." Another positive gesture is to hand patients before and after photos on a card following their treatment sessions, along with a handwritten note from you that says, "Thank you for your trust."

Patient surveys also can help you gauge how you’re doing, but keep them short, such as, "What’s one thing we could have done to improve your experience today?"

• Taking a "one-size-fits-all" approach. Gone are the days when an advertisement in your local newspaper with a menu of services is considered sufficient. Instead, "create one message to a specific market using the one media channel they are most likely in," Ms. Maley said. "For example, a woman in her 60s who is considering a facelift is more likely to respond to a one-on-one phone call or direct mail. Her daughter who is considering blepharoplasty is likely to research the procedure on the Internet."

• Having no marketing plan. Ms. Maley recommended carving out dedicated time with staff and perhaps a marketing consultant to devise a strategy for attracting high-value patients. "First, you have to attract them," she said. "Then, you have to qualify them to make sure they have the financial and emotional wherewithal to want what you offer. Then, you have to convert them to procedures, retain them for a lifetime, obtain testimonials and reviews, and encourage referrals. If you can set up a system that works just like protocols for surgery, it becomes an automatic system," she noted.

Ms. Maley said she had no relevant financial disclosures.

d.brunk@elsevier.com

LAS VEGAS – Do your receptionists, patient coordinators, and other staff members represent you and your practice well? If not, it might be time for you to remind them that their role comes down to supporting you.

"Not knowing who’s on your team is a common marketing mistake," Catherine Maley said at the annual meeting of the American Academy of Cosmetic Surgery. "Nothing is more important in a cosmetic dermatology practice than having the right team in place. Your team is going to make or break your practice, because they are going to spend more time with your patients than you are."

Your staff must represent and promote you as the best choice, Ms. Maley said. "They have to embrace aesthetics," she emphasized. "I’ve been in offices where I’ve heard the receptionist say, ‘I would never get Botox.’ I have also heard a patient care coordinator say, ‘Just so you know, that’s not his best procedure. I would probably go somewhere else for that.’ "

Ms. Maley, a marketing strategist with Sausalito, Calif.–based Cosmetic Image Marketing, said that clinicians can find out which of their staff are true team players by staging a "refer a friend" contest in January or September, which are traditionally slow months for cosmetic dermatology practices. For the contest, employees have 30 days to distribute referral cards to family, friends, and other people in their social network. "At the end of 30 days, have a party and the employee who brings in the most referrals wins a prize – maybe an iPad or cash," Ms. Maley said. "Those who gave you the most referrals you know are on your team. Those who never participated aren’t."

Ms. Maley noted several other common mistakes clinicians make in marketing their practices, including:

• Ignoring your patients. Indifference "costs you, and it allows the gate to be open for your competitors," said Ms. Maley, who is also author of the book "Your Aesthetic Practice: What Your Patients Are Saying" (Sausalito: Cosmetic Imaging Marketing, 2011). "You have a captive market of aging baby boomers, so you want to keep them," she said. "For example, let’s say a patient shows up for a simple peel procedure or to buy a product. If they like what they got, they’re likely to start working their way up to injectables, laser procedures, or skin-tightening procedures. Keep them coming with messages by direct mail, e-mail, and social media," she said.

Although the Internet is fast and easy, don’t put all your eggs in that basket, Ms. Maley added. "You are missing out on half the patients who aren’t reading their e-mail and who can’t get past a computer firewall at work." Direct mail, she continued, offers an opportunity for one-on-one communication with the patient, "which is golden." Face time also builds trust. "The more face time you have with patients, the more they feel like they know you," she said.

• Assuming your patients will refer. Ms. Maley estimated that almost everyone knows about 150 people in their general geographic area, including service providers, family, friends, colleagues, and neighbors. "What if each patient referred one person to you?" she asked. "That could double your patient database. It’s worth asking patients who know you, like you, and trust you to refer at least one person to you."

While asking for referrals may seem awkward for some, she recommended displaying a sign in your waiting room that reads: "We love you as a patient. We would love to have more patients just like you." Another positive gesture is to hand patients before and after photos on a card following their treatment sessions, along with a handwritten note from you that says, "Thank you for your trust."

Patient surveys also can help you gauge how you’re doing, but keep them short, such as, "What’s one thing we could have done to improve your experience today?"

• Taking a "one-size-fits-all" approach. Gone are the days when an advertisement in your local newspaper with a menu of services is considered sufficient. Instead, "create one message to a specific market using the one media channel they are most likely in," Ms. Maley said. "For example, a woman in her 60s who is considering a facelift is more likely to respond to a one-on-one phone call or direct mail. Her daughter who is considering blepharoplasty is likely to research the procedure on the Internet."

• Having no marketing plan. Ms. Maley recommended carving out dedicated time with staff and perhaps a marketing consultant to devise a strategy for attracting high-value patients. "First, you have to attract them," she said. "Then, you have to qualify them to make sure they have the financial and emotional wherewithal to want what you offer. Then, you have to convert them to procedures, retain them for a lifetime, obtain testimonials and reviews, and encourage referrals. If you can set up a system that works just like protocols for surgery, it becomes an automatic system," she noted.

Ms. Maley said she had no relevant financial disclosures.

d.brunk@elsevier.com

LAS VEGAS – Do your receptionists, patient coordinators, and other staff members represent you and your practice well? If not, it might be time for you to remind them that their role comes down to supporting you.

"Not knowing who’s on your team is a common marketing mistake," Catherine Maley said at the annual meeting of the American Academy of Cosmetic Surgery. "Nothing is more important in a cosmetic dermatology practice than having the right team in place. Your team is going to make or break your practice, because they are going to spend more time with your patients than you are."

Your staff must represent and promote you as the best choice, Ms. Maley said. "They have to embrace aesthetics," she emphasized. "I’ve been in offices where I’ve heard the receptionist say, ‘I would never get Botox.’ I have also heard a patient care coordinator say, ‘Just so you know, that’s not his best procedure. I would probably go somewhere else for that.’ "

Ms. Maley, a marketing strategist with Sausalito, Calif.–based Cosmetic Image Marketing, said that clinicians can find out which of their staff are true team players by staging a "refer a friend" contest in January or September, which are traditionally slow months for cosmetic dermatology practices. For the contest, employees have 30 days to distribute referral cards to family, friends, and other people in their social network. "At the end of 30 days, have a party and the employee who brings in the most referrals wins a prize – maybe an iPad or cash," Ms. Maley said. "Those who gave you the most referrals you know are on your team. Those who never participated aren’t."

Ms. Maley noted several other common mistakes clinicians make in marketing their practices, including:

• Ignoring your patients. Indifference "costs you, and it allows the gate to be open for your competitors," said Ms. Maley, who is also author of the book "Your Aesthetic Practice: What Your Patients Are Saying" (Sausalito: Cosmetic Imaging Marketing, 2011). "You have a captive market of aging baby boomers, so you want to keep them," she said. "For example, let’s say a patient shows up for a simple peel procedure or to buy a product. If they like what they got, they’re likely to start working their way up to injectables, laser procedures, or skin-tightening procedures. Keep them coming with messages by direct mail, e-mail, and social media," she said.

Although the Internet is fast and easy, don’t put all your eggs in that basket, Ms. Maley added. "You are missing out on half the patients who aren’t reading their e-mail and who can’t get past a computer firewall at work." Direct mail, she continued, offers an opportunity for one-on-one communication with the patient, "which is golden." Face time also builds trust. "The more face time you have with patients, the more they feel like they know you," she said.

• Assuming your patients will refer. Ms. Maley estimated that almost everyone knows about 150 people in their general geographic area, including service providers, family, friends, colleagues, and neighbors. "What if each patient referred one person to you?" she asked. "That could double your patient database. It’s worth asking patients who know you, like you, and trust you to refer at least one person to you."

While asking for referrals may seem awkward for some, she recommended displaying a sign in your waiting room that reads: "We love you as a patient. We would love to have more patients just like you." Another positive gesture is to hand patients before and after photos on a card following their treatment sessions, along with a handwritten note from you that says, "Thank you for your trust."

Patient surveys also can help you gauge how you’re doing, but keep them short, such as, "What’s one thing we could have done to improve your experience today?"

• Taking a "one-size-fits-all" approach. Gone are the days when an advertisement in your local newspaper with a menu of services is considered sufficient. Instead, "create one message to a specific market using the one media channel they are most likely in," Ms. Maley said. "For example, a woman in her 60s who is considering a facelift is more likely to respond to a one-on-one phone call or direct mail. Her daughter who is considering blepharoplasty is likely to research the procedure on the Internet."

• Having no marketing plan. Ms. Maley recommended carving out dedicated time with staff and perhaps a marketing consultant to devise a strategy for attracting high-value patients. "First, you have to attract them," she said. "Then, you have to qualify them to make sure they have the financial and emotional wherewithal to want what you offer. Then, you have to convert them to procedures, retain them for a lifetime, obtain testimonials and reviews, and encourage referrals. If you can set up a system that works just like protocols for surgery, it becomes an automatic system," she noted.

Ms. Maley said she had no relevant financial disclosures.

d.brunk@elsevier.com

LAS VEGAS – A technique that involves injecting tiny, closely placed amounts of botulinum toxin A to balance the actions of the muscles around the eyebrows yielded natural-looking outcomes without forehead paralysis, based on data from a 5-year study.

"Doctors have mistakenly adopted maximal forehead paralysis as a desirable treatment endpoint," Dr. Kenneth D. Steinsapir said at the annual meeting of the American Academy of Cosmetic Surgery. "Forehead paralysis as a result of cosmetic botulinum toxin is feared by the public and lampooned by the media."

Courtesy Dr. Kenneth D. Steinsapir

Over the years, onabotulinumtoxinA treatments have evolved to create maximal frontalis brow lifts while minimizing the risk of eyelid ptosis. As a result, "the forehead is smooth, but the central forehead is also ptotic," said Dr. Steinsapir of the department of ophthalmology at the University of California, Los Angeles. "There can be recruitment lines on the side of the forehead, which can make for an undesirable treatment effect."

In 2006, Dr. Steinsapir first described the microdroplet botulinum toxin forehead lift, a technique he developed for treating eyebrow depressors that leaves the brow elevator untreated. "I hypothesized that very small quantities of botulinum toxic can be injected and effectively trapped between the skin and the underlying orbicularis oculi muscle in the brow, and in the crow’s feet area as well," said Dr. Steinsapir, who also maintains a private cosmetic surgery practice in Beverly Hills, Calif. "This weakens the eyebrow depressors, allowing the frontalis muscle to lift unopposed, lifting the brows. Forehead movement is preserved and unwanted diffusion responsible for eyelid ptosis is prevented."

Between August 2006 and July 2011, Dr. Steinsapir performed 574 consecutive microdroplet botulinum toxin forehead lift treatments on 175 women and 53 men with a mean age of 45 years. A typical treatment involves 10 mcL of injectable saline containing 0.33 U of botulinum toxin A using the product formulation of Botox or Xeomin. About 100 microinjections are needed to complete the pattern, and all patients in the study received 33 units of Botox exclusively.

Dr. Steinsapir reported that there were no cases of treatment-induced upper eyelid or eyebrow ptosis or cases of diplopia, "which established that this treatment can be safely performed." Of the 574 patients, 49 returned for follow-up appointments between 10 and 45 days after treatment. Before and after images were used to assess the effect of treatment on the upper eyelid margin reflex distance, the tarsal platform show, and the brow position central to the cornea. Dr. Steinsapir used National Institutes of Health imaging software to perform quantitative image analysis and validated facial scales to assess the brow and forehead before and after treatment.

There was no significant change in the margin reflex distance after treatment in the 49 patients who returned for follow-up, Dr. Steinsapir said. "There was a slight trend to minimal brow elevation, and the tarsal platform show was essentially unchanged after treatment," he said. "It’s my clinical impression that the principal effect of the treatment is the softening of the brow pinch that commonly purses the brow and brings an unintentional negative affect to the face."

Dr. Steinsapir acknowledged that the procedure requires a learning curve "and a need to educate patients regarding the effect of treatment. This is more labor intensive than standard treatment methods." Dr. Steinsapir has developed a detailed training video that is available online on his website, and he said that he is working on a treatment atlas.

The microdroplet botulinum toxin forehead lift "presents the first alternative to standard periocular treatments that cause unwarranted forehead paralysis, brow flare, or muscle activation," Dr. Steinsapir said. "By controlling the depth, volume, and dose of agent, very controlled brow shaping and lifting can be performed to create aesthetic improvement with natural results, including preservation of forehead movement," he noted.

Dr. Steinsapir received a United States patent on the microdroplet method. He said that he hopes to license the technique to a drug company for the development of a Food and Drug Administration–approved indication, so the treatment can be directly marketed to consumers. He had no other relevant financial conflicts to disclose.

d.brunk@elsevier.com

LAS VEGAS – A technique that involves injecting tiny, closely placed amounts of botulinum toxin A to balance the actions of the muscles around the eyebrows yielded natural-looking outcomes without forehead paralysis, based on data from a 5-year study.

"Doctors have mistakenly adopted maximal forehead paralysis as a desirable treatment endpoint," Dr. Kenneth D. Steinsapir said at the annual meeting of the American Academy of Cosmetic Surgery. "Forehead paralysis as a result of cosmetic botulinum toxin is feared by the public and lampooned by the media."

Courtesy Dr. Kenneth D. Steinsapir

Over the years, onabotulinumtoxinA treatments have evolved to create maximal frontalis brow lifts while minimizing the risk of eyelid ptosis. As a result, "the forehead is smooth, but the central forehead is also ptotic," said Dr. Steinsapir of the department of ophthalmology at the University of California, Los Angeles. "There can be recruitment lines on the side of the forehead, which can make for an undesirable treatment effect."

In 2006, Dr. Steinsapir first described the microdroplet botulinum toxin forehead lift, a technique he developed for treating eyebrow depressors that leaves the brow elevator untreated. "I hypothesized that very small quantities of botulinum toxic can be injected and effectively trapped between the skin and the underlying orbicularis oculi muscle in the brow, and in the crow’s feet area as well," said Dr. Steinsapir, who also maintains a private cosmetic surgery practice in Beverly Hills, Calif. "This weakens the eyebrow depressors, allowing the frontalis muscle to lift unopposed, lifting the brows. Forehead movement is preserved and unwanted diffusion responsible for eyelid ptosis is prevented."

Between August 2006 and July 2011, Dr. Steinsapir performed 574 consecutive microdroplet botulinum toxin forehead lift treatments on 175 women and 53 men with a mean age of 45 years. A typical treatment involves 10 mcL of injectable saline containing 0.33 U of botulinum toxin A using the product formulation of Botox or Xeomin. About 100 microinjections are needed to complete the pattern, and all patients in the study received 33 units of Botox exclusively.

Dr. Steinsapir reported that there were no cases of treatment-induced upper eyelid or eyebrow ptosis or cases of diplopia, "which established that this treatment can be safely performed." Of the 574 patients, 49 returned for follow-up appointments between 10 and 45 days after treatment. Before and after images were used to assess the effect of treatment on the upper eyelid margin reflex distance, the tarsal platform show, and the brow position central to the cornea. Dr. Steinsapir used National Institutes of Health imaging software to perform quantitative image analysis and validated facial scales to assess the brow and forehead before and after treatment.

There was no significant change in the margin reflex distance after treatment in the 49 patients who returned for follow-up, Dr. Steinsapir said. "There was a slight trend to minimal brow elevation, and the tarsal platform show was essentially unchanged after treatment," he said. "It’s my clinical impression that the principal effect of the treatment is the softening of the brow pinch that commonly purses the brow and brings an unintentional negative affect to the face."

Dr. Steinsapir acknowledged that the procedure requires a learning curve "and a need to educate patients regarding the effect of treatment. This is more labor intensive than standard treatment methods." Dr. Steinsapir has developed a detailed training video that is available online on his website, and he said that he is working on a treatment atlas.

The microdroplet botulinum toxin forehead lift "presents the first alternative to standard periocular treatments that cause unwarranted forehead paralysis, brow flare, or muscle activation," Dr. Steinsapir said. "By controlling the depth, volume, and dose of agent, very controlled brow shaping and lifting can be performed to create aesthetic improvement with natural results, including preservation of forehead movement," he noted.

Dr. Steinsapir received a United States patent on the microdroplet method. He said that he hopes to license the technique to a drug company for the development of a Food and Drug Administration–approved indication, so the treatment can be directly marketed to consumers. He had no other relevant financial conflicts to disclose.

d.brunk@elsevier.com

LAS VEGAS – A technique that involves injecting tiny, closely placed amounts of botulinum toxin A to balance the actions of the muscles around the eyebrows yielded natural-looking outcomes without forehead paralysis, based on data from a 5-year study.

"Doctors have mistakenly adopted maximal forehead paralysis as a desirable treatment endpoint," Dr. Kenneth D. Steinsapir said at the annual meeting of the American Academy of Cosmetic Surgery. "Forehead paralysis as a result of cosmetic botulinum toxin is feared by the public and lampooned by the media."

Courtesy Dr. Kenneth D. Steinsapir

Over the years, onabotulinumtoxinA treatments have evolved to create maximal frontalis brow lifts while minimizing the risk of eyelid ptosis. As a result, "the forehead is smooth, but the central forehead is also ptotic," said Dr. Steinsapir of the department of ophthalmology at the University of California, Los Angeles. "There can be recruitment lines on the side of the forehead, which can make for an undesirable treatment effect."

In 2006, Dr. Steinsapir first described the microdroplet botulinum toxin forehead lift, a technique he developed for treating eyebrow depressors that leaves the brow elevator untreated. "I hypothesized that very small quantities of botulinum toxic can be injected and effectively trapped between the skin and the underlying orbicularis oculi muscle in the brow, and in the crow’s feet area as well," said Dr. Steinsapir, who also maintains a private cosmetic surgery practice in Beverly Hills, Calif. "This weakens the eyebrow depressors, allowing the frontalis muscle to lift unopposed, lifting the brows. Forehead movement is preserved and unwanted diffusion responsible for eyelid ptosis is prevented."

Between August 2006 and July 2011, Dr. Steinsapir performed 574 consecutive microdroplet botulinum toxin forehead lift treatments on 175 women and 53 men with a mean age of 45 years. A typical treatment involves 10 mcL of injectable saline containing 0.33 U of botulinum toxin A using the product formulation of Botox or Xeomin. About 100 microinjections are needed to complete the pattern, and all patients in the study received 33 units of Botox exclusively.

Dr. Steinsapir reported that there were no cases of treatment-induced upper eyelid or eyebrow ptosis or cases of diplopia, "which established that this treatment can be safely performed." Of the 574 patients, 49 returned for follow-up appointments between 10 and 45 days after treatment. Before and after images were used to assess the effect of treatment on the upper eyelid margin reflex distance, the tarsal platform show, and the brow position central to the cornea. Dr. Steinsapir used National Institutes of Health imaging software to perform quantitative image analysis and validated facial scales to assess the brow and forehead before and after treatment.

There was no significant change in the margin reflex distance after treatment in the 49 patients who returned for follow-up, Dr. Steinsapir said. "There was a slight trend to minimal brow elevation, and the tarsal platform show was essentially unchanged after treatment," he said. "It’s my clinical impression that the principal effect of the treatment is the softening of the brow pinch that commonly purses the brow and brings an unintentional negative affect to the face."

Dr. Steinsapir acknowledged that the procedure requires a learning curve "and a need to educate patients regarding the effect of treatment. This is more labor intensive than standard treatment methods." Dr. Steinsapir has developed a detailed training video that is available online on his website, and he said that he is working on a treatment atlas.

The microdroplet botulinum toxin forehead lift "presents the first alternative to standard periocular treatments that cause unwarranted forehead paralysis, brow flare, or muscle activation," Dr. Steinsapir said. "By controlling the depth, volume, and dose of agent, very controlled brow shaping and lifting can be performed to create aesthetic improvement with natural results, including preservation of forehead movement," he noted.

Dr. Steinsapir received a United States patent on the microdroplet method. He said that he hopes to license the technique to a drug company for the development of a Food and Drug Administration–approved indication, so the treatment can be directly marketed to consumers. He had no other relevant financial conflicts to disclose.

d.brunk@elsevier.com